Scientific letter
CT-guided Methylene Blue Labeling to Locate a Pulmonary Nodule Before Thoracoscopic Resection
Instilación de azul de metileno guiado por tomografía axial computarizada para localizar y resecar mediante toracoscopia un nódulo pulmonar
Yolanda Martínez Criado
, Sonia Pérez Bertólez, Rosa Cabello Laureano, Juan Carlos de Agustín Asensio
Corresponding author
Servicio de Cirugía pediátrica, Hospital Virgen del Rocío, Sevilla, Spain
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"yoli84mc@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Sonia" "apellidos" => "Pérez Bertólez" ] 2 => array:2 [ "nombre" => "Rosa" "apellidos" => "Cabello Laureano" ] 3 => array:2 [ "nombre" => "Juan Carlos" "apellidos" => "de Agustín Asensio" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cirugía pediátrica, Hospital Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Instilación de azul de metileno guiado por tomografía axial computarizada para localizar y resecar mediante toracoscopia un nódulo pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 798 "Ancho" => 1867 "Tamanyo" => 151233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Injection of methylene blue at the 5th intercostal space on the mid-axillary line.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Video-assisted thoracoscopy is a minimally invasive procedure that is routinely used for the resection of pulmonary nodules in pediatric surgery. However, its use may be limited in the case of small lesions (less than 1<span class="elsevierStyleHsp" style=""></span>cm) or those located deep within the lung parenchyma with no pleural contact. Thoracoscopic instruments do not have the tactile sensation of a surgeon's hand, so preoperative marking of the lesion with radiologic techniques is necessary for proper resection.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case in which the combined use of radiological techniques and marking of the lesion with methylene blue provided direct visualization of a nodule, which resulted in successful resection with video-assisted thoracoscopy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case Report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 12-year-old boy with a history of right nephrectomy due to spindle cell sarcoma in 2007. In 2008, a spinal metastasis required arthrodesis of T9. A follow-up PET-CT in 2009 revealed a posterior-basal lesion with high uptake in the right lower lobe suggestive of pulmonary metastasis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to its peripheral location and because it was not in close contact with the pleura (3<span class="elsevierStyleHsp" style=""></span>mm deep), as well as its small diameter (7<span class="elsevierStyleHsp" style=""></span>mm), we decided to mark the nodule using computer tomography (CT) guidance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In the radiology room, under general anesthesia and using face masks, a needle puncture was performed through the 5<span class="elsevierStyleSup">th</span> intercostal space, guided by CT, and methylene blue was injected (0.1<span class="elsevierStyleHsp" style=""></span>ml) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Afterwards, the patient was transferred to the operating room to begin surgery as soon as possible in order to prevent the diffusion of the injected methylene blue. We proceeded with the selective intubation of the left main bronchus with a flexible bronchoscope, positioning the child in the left lateral decubitus position to start thoracoscopic resection. Three triangulated ports (two 5-mm and one 12-mm) were inserted and, with a 30° camera and ENDOGIA, a wedge measuring 3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm was resected, including the nodule with healthy margins. Direct visualization of the punctured area that had been stained blue allowed us to locate the nodule and remove it with safety margins. At the end of the operation, the CO<span class="elsevierStyleInf">2</span> was extracted and a chest tube was not required.</p><p id="par0030" class="elsevierStylePara elsevierViewall">During the post-op period, pain was controlled with oral analgesia. Follow-up chest radiography showed no residual pneumothorax, and the patient was discharged 12<span class="elsevierStyleHsp" style=""></span>h after surgery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The pathology study of the surgical specimen revealed that it was a pulmonary metastasis of the renal spindle cell sarcoma.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Video-assisted thoracoscopic surgery (VATS) is currently the approach of choice for the resection of peripheral single lung nodules for both diagnostic and therapeutic purposes. The combined use of radiological techniques for marking small nodules with no pleural contact allows for adequate visualization of the area to resect, while resolving the limitations of thoracoscopic resection.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The puncture is performed in the intercostal space, close to the upper edge of the rib to avoid injury to the intercostal nerve bundle. With CT guidance, the needle or harpoon is positioned in the exact area of the lesion and a small amount of methylene blue is injected. CT-guided tumor marking is a simple and safe procedure that can be performed in the radiology room, after which the patient is transferred to the operating room. It always requires general anesthesia, and its most common complication is pneumothorax.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> The main drawback of this technique is the fast, high rate of diffusion of methylene blue. It may be helpful to dilute it with autologous blood from the patient and inject the minimum amount required; the surgery should be performed immediately within the hour, if possible.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The advantages of this minimally invasive surgery versus traditional thoracotomy are: less postoperative pain, better recovery of lung function, lower systemic inflammatory response, shorter hospital stay, better esthetic results and less thoracic deformity with the growth of the child. The difficulties and limitations of thoracoscopy can be resolved with the support of radiological localization and marking procedures of small, deep nodules.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">During the procedure, the radiologist, anesthetist and pediatric surgeon should work as a perfectly coordinated team.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martínez Criado Y, Pérez Bertólez S, Cabello Laureano R, de Agustín Asensio JC. Instilación de azul de metileno guiado por tomografía axial computarizada para localizar y resecar mediante toracoscopia un nódulo pulmonar. Cir Esp. 2014;92:139–141.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 602 "Ancho" => 1867 "Tamanyo" => 122416 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Localization of the lesion with computed tomography; (B) CT-guided needle puncture.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 798 "Ancho" => 1867 "Tamanyo" => 151233 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Injection of methylene blue at the 5th intercostal space on the mid-axillary line.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracoscopy for the diagnosis of the indeterminate solitary pulmonary nodule" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 14 | 2 | 16 |
| 2024 September | 36 | 3 | 39 |
| 2024 August | 25 | 2 | 27 |
| 2024 July | 31 | 8 | 39 |
| 2024 June | 23 | 6 | 29 |
| 2024 May | 32 | 3 | 35 |
| 2024 April | 31 | 3 | 34 |
| 2024 March | 37 | 6 | 43 |
| 2024 February | 43 | 1 | 44 |
| 2024 January | 41 | 4 | 45 |
| 2023 December | 55 | 2 | 57 |
| 2023 November | 56 | 6 | 62 |
| 2023 October | 73 | 15 | 88 |
| 2023 September | 33 | 4 | 37 |
| 2023 August | 48 | 3 | 51 |
| 2023 July | 51 | 6 | 57 |
| 2023 June | 34 | 9 | 43 |
| 2023 May | 71 | 3 | 74 |
| 2023 April | 43 | 0 | 43 |
| 2023 March | 58 | 2 | 60 |
| 2023 February | 36 | 5 | 41 |
| 2023 January | 45 | 4 | 49 |
| 2022 December | 27 | 4 | 31 |
| 2022 November | 53 | 10 | 63 |
| 2022 October | 39 | 12 | 51 |
| 2022 September | 38 | 17 | 55 |
| 2022 August | 43 | 15 | 58 |
| 2022 July | 34 | 6 | 40 |
| 2022 June | 24 | 6 | 30 |
| 2022 May | 31 | 3 | 34 |
| 2022 April | 26 | 12 | 38 |
| 2022 March | 50 | 8 | 58 |
| 2022 February | 58 | 8 | 66 |
| 2022 January | 56 | 6 | 62 |
| 2021 December | 30 | 23 | 53 |
| 2021 November | 33 | 7 | 40 |
| 2021 October | 46 | 9 | 55 |
| 2021 September | 27 | 13 | 40 |
| 2021 August | 32 | 7 | 39 |
| 2021 July | 24 | 8 | 32 |
| 2021 June | 43 | 12 | 55 |
| 2021 May | 42 | 10 | 52 |
| 2021 April | 101 | 31 | 132 |
| 2021 March | 26 | 12 | 38 |
| 2021 February | 27 | 5 | 32 |
| 2021 January | 29 | 15 | 44 |
| 2020 December | 21 | 14 | 35 |
| 2020 November | 28 | 12 | 40 |
| 2020 October | 11 | 11 | 22 |
| 2020 September | 14 | 9 | 23 |
| 2020 August | 22 | 9 | 31 |
| 2020 July | 29 | 11 | 40 |
| 2020 June | 26 | 8 | 34 |
| 2020 May | 21 | 6 | 27 |
| 2020 April | 21 | 8 | 29 |
| 2020 March | 37 | 3 | 40 |
| 2020 February | 29 | 6 | 35 |
| 2020 January | 40 | 6 | 46 |
| 2019 December | 59 | 12 | 71 |
| 2019 November | 36 | 24 | 60 |
| 2019 October | 44 | 6 | 50 |
| 2019 September | 31 | 6 | 37 |
| 2019 August | 26 | 4 | 30 |
| 2019 July | 26 | 31 | 57 |
| 2019 June | 53 | 14 | 67 |
| 2019 May | 118 | 30 | 148 |
| 2019 April | 75 | 22 | 97 |
| 2019 March | 19 | 5 | 24 |
| 2019 February | 19 | 9 | 28 |
| 2019 January | 14 | 5 | 19 |
| 2018 December | 13 | 7 | 20 |
| 2018 November | 15 | 7 | 22 |
| 2018 October | 28 | 12 | 40 |
| 2018 September | 11 | 3 | 14 |
| 2018 August | 4 | 5 | 9 |
| 2018 July | 7 | 4 | 11 |
| 2018 June | 7 | 4 | 11 |
| 2018 May | 9 | 8 | 17 |
| 2018 April | 11 | 4 | 15 |
| 2018 March | 6 | 2 | 8 |
| 2018 February | 5 | 1 | 6 |
| 2018 January | 6 | 2 | 8 |
| 2017 December | 16 | 4 | 20 |
| 2017 November | 11 | 6 | 17 |
| 2017 October | 17 | 5 | 22 |
| 2017 September | 9 | 7 | 16 |
| 2017 August | 14 | 1 | 15 |
| 2017 July | 5 | 6 | 11 |
| 2017 June | 16 | 6 | 22 |
| 2017 May | 17 | 4 | 21 |
| 2017 April | 10 | 3 | 13 |
| 2017 March | 20 | 21 | 41 |
| 2017 February | 12 | 5 | 17 |
| 2017 January | 10 | 2 | 12 |
| 2016 December | 12 | 7 | 19 |
| 2016 November | 17 | 1 | 18 |
| 2016 October | 33 | 4 | 37 |
| 2016 September | 18 | 6 | 24 |
| 2016 August | 16 | 5 | 21 |
| 2016 July | 20 | 2 | 22 |
| 2016 June | 13 | 6 | 19 |
| 2016 May | 26 | 22 | 48 |
| 2016 April | 14 | 12 | 26 |
| 2016 March | 20 | 15 | 35 |
| 2016 February | 18 | 7 | 25 |
| 2016 January | 19 | 5 | 24 |
| 2015 December | 18 | 11 | 29 |
| 2015 November | 15 | 4 | 19 |
| 2015 October | 26 | 9 | 35 |
| 2015 September | 30 | 4 | 34 |
| 2015 August | 31 | 8 | 39 |
| 2015 July | 25 | 2 | 27 |
| 2015 June | 7 | 2 | 9 |
| 2015 May | 13 | 8 | 21 |
| 2015 April | 26 | 12 | 38 |
| 2015 March | 20 | 9 | 29 |
| 2015 February | 20 | 8 | 28 |
| 2015 January | 16 | 3 | 19 |
| 2014 December | 43 | 13 | 56 |
| 2014 November | 28 | 3 | 31 |
| 2014 October | 17 | 8 | 25 |
| 2014 September | 27 | 3 | 30 |
| 2014 August | 26 | 2 | 28 |
| 2014 July | 32 | 5 | 37 |
| 2014 June | 18 | 4 | 22 |
| 2014 May | 22 | 4 | 26 |
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